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Implant Stability - Measuring Devices
and Randomized Clinical Trial for ISQ
Value Change Pattern Measured from Two
Different Directions by Magnetic RFA
Jong-Chul Park, Jung-Woo Lee,
Soung-Min Kim and Jong-Ho Lee
Department of Oral and Maxillofacial Surgery,
School of Dentistry, Seoul National University,
Seoul,
Korea
1. Introduction
Implant stability plays a critical role for successful osseointegration, which has been
viewed as a direct structural and functional connection existing between bone and the
surface of a load-carrying implant(Bränemark, et al. 1977, Sennerby & Roos 1998).
Achievement and maintenance of implant stability are prerequisites for successful clinical
outcome(Sennerby & Meredith 2008). Therefore, measuring the implant stability is an
important method for evaluating the success of an implant. Implant stability is achieved
at two different stages: primary and secondary. Primary stability of an implant comes
from mechanical engagement with cortical bone. It is affected by the quantity and quality
of bone that the implant is inserted into, surgical procedure, length, diameter, and form of
the implant(Meredith 1998).
Secondary stability is developed from regeneration and remodeling of the bone and tissue
around the implant after insertion but is affected by the primary stability, bone formation
and remodeling(Sennerby & Roos 1998). The time of functional loading is dependent upon
the secondary stability. It is, therefore, of an utmost importance to be able to quantify
implant stability at various time points and to project a long term prognosis based on the
measured implant stability(Atsumi, et al. 2007).
2. Measuring analyses of implant stability
Presently, various diagnostic analyses have been suggested to define implant stability.
Primary implant stability can be measured by either a destructive or a non-destructive
method. Histomorphologic research, tensional test, push-out/pull-out test and removal
torque test are classified as destructive methods. Non-destructive methods include
percussion test, radiography, cutting torque test while placing implants, Periotest®(Siemens
AG, Benshein, Germany), and resonance frequency analysis(RFA)(Meredith 1998).
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Implant Dentistry  A Rapidly Evolving Practice112
2.1 Tensional test
The interfacial tensile strength was originally measured by detaching the implant plate from
the supporting bone(Kitsugi, et al. 1996). Bränemark later modified this technique by
applying the lateral load to the implant fixture(Bränemark, et al. 1998). However, they also
addressed the difficulties of translating the test results to any area- independent mechanical
properties(Chang, et al. 2010)(Fig. 1a).
2.2 Histomorphometric analysis
Histomorphometric analysis is obtained by calculating the peri-implant bone quantity and
bone-implant contact(BIC) from a dyed specimen of the implant and peri-implant bone.
Accurate measurement is an advantage, but due to the invasive and destructive procedure,
it is not appropriate for long-term studies. It is used in non-clinical studies and experiments.
2.2 Push-out/pull-out test
The ‘push-out’ or ‘pull-out’ test is the most commonly used approach to investigate the
healing capabilities at the bone implant interface(Brunski, et al. 2000). In the typical push-
out or pull-out test, a cylinder-type implant is placed transcortically or intramedullarly in
Fig. 1. Stability analyses for oral implant osseointegration from Chang, P. C., Lang, N. P. &
Giannobile, W. V. (2010). “Evaluation of functional dynamics during osseointegration and
regeneration associated with oral implants.” Clinical Oral Implants Research 21: 1-12. (a)
tensional test, (b) push-out test, (c) pull-out test, (d) insertional/removal torque test, (e)
Periotest, and (e) resonance frequency analysis (RFA).
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bone structures and then removed by applying a force parallel to the interface. The
maximum load capability (or failure load) is defined as the maximum force on the force–
displacement plot, and the interfacial stiffness is visualized as the slope of a tangent
approximately at the linear region of the force–displacement curve before breakpoint
(Brunski, et al. 2000, Lutolf, et al. 2003). Therefore, the general loading capacity of the
interface (or interfacial shear strength) can be measured by dividing the maximum force by
the area of implant in contact with the host bone(Berzins, et al. 1997). However, the push-out
and pull-out tests are only applicable for non-threaded cylinder type implants, whereas
most of clinically available fixtures are of threaded design, and their interfacial failures are
solely dependent on shear stress without any consideration for either tensile or compressive
stresses(Brunski, et al. 2000, Chang, et al. 2010)(Fig. 1b-c).
2.3 Removal torque analysis
Application of a reverse or unscrewing torque has also been proposed for the assessment of
implant stability at the time of abutment connection(Sullivan, et al. 1996), however, implant
surface in the process of osseointegration may fracture under the applied torque
stress(Ivanoff, et al. 1997)(Fig.1d).
2.4 Percussion test
The test is carried out by a simple percussion with the handle of a dental instrument on the
implant abutment and listening to the resulting sound. However, this method may be
subjective according to the examiner and give inaccurate measurements for implants
because of the high rigidity of implants and the lack of periodontal ligaments.
2.5 Insertion torque measurement
Insertion torque values have been used to measure the bone quality in various parts of the
jaw during implant placement(O'Sullivan, et al. 2004). Insertion torque alone may be used as
an independent stability measurement, but it may also act as a variable, affecting implant
stability. In a different light, insertion torque is a mechanical parameter generally affected by
surgical procedure, implant design and bone quality at implant site(Beer, et al. 2003).
However, it cannot assess the secondary stability by new bone formation and remodeling
around the implant. So it cannot collect longitudinal data to assess implant stability change
after placement. Also, an increase in insertion torque may signify an increase in primary
stability, but maximum insertion torque is produced by the pressure of implant neck on the
dense cortical bone of the alveolus. Furthermore, it has been reported that if maximum
insertion torque doesn’t signify increased general bone density, it may indicate the insertion
torque itself during tapping (Calandriello, et al. 2003)(Fig.1d).
2.6 Radiography
Radiography provides useful information for evaluating the quantity and quality of bone in
the area for an implant before placing the fixture. It is also helpful in predicting implant
stability by observing the process of osseointegration or peri-implant lesions. However,
there is a limitation in image resolution and standardized X-rays are difficult to achieve due
to the distortion of images, making quantitative measurements more challenging. In
addition, it is difficult to perceive changes in the bone structures and morphology of the
implant-bone interface unless over 30% bone loss occurs. Although the accuracy of the
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Implant Dentistry  A Rapidly Evolving Practice114
diagnosis is low, radiography is the major method used clinically to evaluate
osseointegration and implant stability because of its convenience. (Albrektsson, et al. 1986).
2.7 Periotest®
Periotest® (Siemens AG, Benshein, Germany) was originally devised by Dr. Schulte to
measure tooth mobility(Fig.2). Teerlinck, et al.(1991) used this method to overcome
destructive methods in measuring the implant stability. Periotest® evaluates the damping
capacity of the periodontium. It is designed to identify the damping capacity and the
stiffness of the natural tooth or implant by measuring the contact time of an electronically
driven and electronically monitored rod after percussing the test surface. Periotest
value(PTV) is marked from -8(low mobility) to +50(high mobility). PTV of -8 to -6 is
considered good stability.
Periotest® can measure all surfaces such as the abutment or prosthesis, but the rod must make
contact at a correct angle and distance. If the perpendicular contact angle is larger than 20
degrees, or if the parallel contact angle is larger than 4 degrees, the measured value is invalid.
Also, the rod and the test surface must maintain 0.6-2.0mm distance and if the distance is over
5mm, the measured value may be insignificant. (Ito, et al. 2008, Schulte 1988). Periotest® has
limited clinical use since it cannot measure the mesiodistal mobility and the position and angle
of the rod affects the measured value. Also, it cannot detect the small changes in the implant-
bone surface. The most failing point of this method is that the percussing force on the implant
may deteriorate the stability in poor initial stability implants.
(a) (b)
Fig. 2. Periotest® (Siemens AG, Benshein, Germany) measures tooth mobility and implant
stability by periotest value(PTV). (a) Periotest®, (B) Periotest®M.
2.8 Resonance Frequency Analysis(RFA)
In 1998, Meredith suggested a non-invasive method of analyzing peri-implant bone by
connecting an adapter to an implant in an animal study. The experimented resonance
frequency analysis system was commercially produced as OsstellTM (Osstell AB, Göteborg,
Sweden).
A measurement of OsstellTM is displayed as implant stability quotient(ISQ) from 1 to 100,
where 100 signifies the highest implant stability. OsstellTM was later followed by OsstellTM
Mentor, and OsstellTM ISQ.
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3. RFA principle and application
3.1 Introduction
Meredith et al.(1996) reported the use of resonance frequency analyzer to evaluate implant
stability by applying architectural engineering, and proved in early in vitro test the ability of
the device in evaluating the stiffness change of the surface. RFA uses the principle of when a
frequency of audibility range is repeatedly vibrated onto an implant, the stronger the bone-
implant surface, resonance occurs in a higher frequency. The first commercial product of the
resonance frequency analyzer(RFA) was OsstellTM(Osstell AB, Göteborg, Sweden)(Fig.3),
followed by OsstellTM Mentor and recently OsstellTM ISQ was introduced. OsstellTM uses
electronic technology and other devices(OsstellTM Mentor, OsstellTM ISQ) use magnetic
technology (Fig.5).
(a) (b)
Fig. 3. Pictures showing the first commercial products of resonance frequency analyzer. (a)
the OsstellTM and (b) the application of the OsstellTM electronic transducer to the
implant.(The figure and illustration are cited with permission from Osstell website,
www.osstell.com, April, 2011)
3.2 Electronic technology resonance frequency analyzer(Osstell
TM
)
The primary model OsstellTM produces alternating sine waves in a specific frequency range
by uniform amplitude and makes the transducer connected to the implant or abutment
vibrate under 1mm like an electronic tuning fork. A cantilever small beam is connected to
the transducer and on this beam, 2 piezo-ceramic elements are attached. (Fig.3,4). One of
them receives the signal and vibrates the transducer, and the other passes this vibration to
the resonance frequency analyzer. Values on the monitor are displayed from 0-100 so that it
can be conveniently used clinically. The value of 100 signify the highest stability state.
Generally ISQ values for successfully integrated implants are reported from 57 to 82. These
values can be displayed by graphs on the computer monitor or be expressed by values
between 4500-8500Hz. The obtained output can be calculated by the equation below.
= α
EI
ρl
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is the RF of the beam, l is the effective vibration length of the beam, E is the Young`s
modulus, I is the moment of inertia, ρ is the mass, α the constant that increases as peri-
implant bone density increases. Therefore, when osseointegration is achieved, RF increases
since α value increases. ‘l’ signifies the length of implant above the bone. So as bone is
resorbed, this value increases and thus RF decreases. In other words, ISQ is affected by the
effective implant length, type of bone at implant site and bone density(Huang, et al. 2003,
Huang, et al. 2003, Meredith, et al. 1996).
Fig. 4. Picture showing the principle of electronic resonance frequency analyzer. (The figure
and illustration are cited from Osstell website, www.osstell.com, April, 2011)
3.3 Magnetic technology resonance frequency analyzer(Osstell
TM
Mentor, Osstell
TM
ISQ)
Resonance frequency between 3.5 KHz and 8.5 KHz formed from the magnetic field is
converted into ISQ values by Osstell MentorTM(Fig. 5, 6). The transducer of Osstell MentorTM
(a) (b)
Fig. 5. Osstell MentorTM and Osstell ISQTM , both of devices measure ISQs by the magnetic
technology. (The pictures are cited from Osstell website, www.osstell.com, April, 2011)
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(a) (b)
Fig. 6. Principle of the Osstell MentorTM. Magnetic peg(Smart pegTM) works like a tuning
fork. Red arrow is the Smart pegTM. (The figure and illustration are cited from Osstell
website, www.osstell.com, April, 2011)
has a magnetic peg on the top and is fixed to the implant fixture or abutment by a screw
below. When magnetic resonance frequency is released from the probe, the magnetic peg is
activated. The activated peg starts to vibrate, and the magnet induces electric volt into the
probe coil and the electric volt is sampled by the magnetic resonance frequency analyzer
(Fig. 6). The values are expressed as numbers between 1–100 in ISQ as OsstellTM
(Valderrama, et al. 2007).
The device is relatively expensive, and each implant system requires the respective
transducer for OsstellTM and magnetic peg for Osstell MentorTM. The restricted use of the
transducer and the magnetic peg is a great disadvantage. Also, evaluation is impossible in a
prosthesis state or when the magnetic peg is damaged or when in contact with the soft
tissue. Therefore, when using Osstell MentorTM, the Smart pegTM must maintain a distance
of approximately 1-3 mm, angle of 90 degrees, and 3 mm above the soft tissue, otherwise the
measured value may be affected (Fig. 7). Valderrama et al.(2007) reported in a study
experimenting the correlation between OsstellTM and Osstell MentorTM that the two devices
had high significant correlation.
3.4 Influencing factors of Implant Stability Quotient(ISQ)
In many literature, it has been reported that ISQ is affected by implant diameter, surface,
form, bone contact ratio, implant site, implant system, surgical procedure, bone quality and
bone height (Atsumi, et al. 2007). RFA is determined by the changes in the interface stiffness,
and it is affected in three aspects. First, bone-implant surface stiffness affects RFA and it
increases through bone healing and remodeling. Secondly, the stiffness of bone itself, and
bone density as well as the ratio of cortical and cancellous bone affects RFA. Finally, the
stiffness of implant components can acts as a variable and it is affected by the interlocking
structures, and the composing elements of the materials. Bone and implant surface stiffness
may be affected by using a small-diameter final drill, changes in surgical techniques such as
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Implant Dentistry  A Rapidly Evolving Practice118
(a) (b)
(c)
Fig. 7. Application of magnetic RFA(OsstellTM Mentor) after immediate implant installation.
The manufacturer recommends that the probe be held perpendicular to the alveolar crest(a)
for the first measurement, and in line with the crest for the other measurement(b). And the
Smart pegTM must maintain a distance of approximately 1-3 mm, angle of 90 degrees, and 3
mm above the soft tissue(c).
bone compaction technique, self-tapping design implants and wide tapered implants, but
not by implant length. In a histomorphologic study, it was reported that the resonance
frequency value is highly correlated with the bone-implant contact amount(Friberg, et al.
1999, Meredith, et al. 1997). There are reports showing a correlation between RFA and the
histomorphometric analysis, and other reports claim that the correlation between the bone
density and ISQ is not significant. Therefore RFA signifies the bone anchorage of implants
but the relation of RFA and bone structure is not yet clear (Alsaadi, et al. 2007, Huwiler, et
al. 2007, Rasmusson, et al. 1998, Zhou, et al. 2008). Such diverse results showed RFA value
decreases during the first 2 weeks after implant placement, and this change can be related to
early bone healing such as biological change and marginal alveolar bone resorption. Bone
remodeling reduces primary bone contact and in the early stage after implant placement, the
formation of bony callus and increasing lamellar bone in the cortical bone causes major
changes in bone density. Thus, in the healing process, primary bone contact decreases and
secondary bone contact increases (Barewal, et al. 2003, Zhou, et al. 2008). Also, the 3–
dimensional implant-bone contact is displayed 2 dimensionally in the histological sample
and BIC has possibility of inaccuracy to signify bone-implant contact (Perrotti, et al. 2010).
The relationship of bone structure and RFA is not fully understood. Since primary stability
is affected by bone volume or bone trabecula structure as well as cortical bone thickness and
density, the effect of bone quality on implant stability cannot be explained by bone
microstructure alone (Huwiler, et al. 2007).
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4. Which device is more accurate to determine the stability of dental implants
- recent literature review
There are two groups of non-invasice devices. One is the RFA analyzer group and the other
is the mobility measuring device. The OsstellTM is the commercial name of the RFA analyzer
group. This device has a cable which is linked a electronic transducer (Fig. 3). The later
version of the OsstellTM is the OssetellTM mentor which has no cable and uses of magnetic
resonance frequency (Fig. 5). Periotest® is the commercial name of the mobility measuring
device. Periotest® M is the newer device of the Periotest® and it is a wireless version (Fig. 2).
4.1 PTV and ISQ
Many studies have indicated the presence of correlation between PTVs(the values of
Periotest®) and ISQ (the values of OsstellTM and OssetellTM mentor). However, the
correlation of implant stability and each value are still the controversial issue. Aparicio et al.
(2006) presentd that the validity and relevance of both ISQ and PTVs for clinical use have to
be questioned in their review article. Lachmann et al. (2006) compared OsstellTM and
Periotest® by in vitro study and demonstrated that both methods are useful in the evaluation
of implant stability but the OsstellTM was more precise than the Periotest® to determine the
actual dental implant stability at peri-implant defects. Zix et al. (2008) studied with
controlled clinical trial and concluded that Periotest® values appear to be more susceptible
to clinical conditions and the OsstellTM instrument seemed to be more precise than the
Periotest®. Winter et al.(2010) investigated the correlation between the two devices through
the finite element study and demonstrated that Periotest® values had only good correlation
with implant stability in case when there’s no bone loss. Oh et al.(2009) reported that the
Periotest® and OsstellTM Mentor were useful and comparably reliable, showing a strong
association with each other in assessing implant stability in their experimental study. In
summarizing the literature, it is generally accepted that the RFA is more accurate than the
mobility measuring device, but the mobility measuring device is more convenient in clinical
usage than RFA (Fig.8).
(a) (b)
Fig. 8. Application of Periotest® M. This device can measure the implant stability and
mobility of natural teeth without special device, for example magnetic peg. (a) is the
application of Periotest® M to natural tooth. (b) is the measurement of implant stability
during follow-up period without implant crown removal.
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4.2 Electronic resonance frequency and magnetic resonance frequency
Valderrama et al.(2007) performed clinical research using electronic- and magnetic-based
devices on 34 non-submerged titanium dental implants in 17 patients and demonstrated that
changes in implant stability measured with the magnetic device correlate well with those
found with the electronic device. Both devices confirmed the initial decreases in implant
stability that occur following placement and identified an increase in stability during the first 6
weeks of functional loading. Tozum et al.(2010) compared three devices which are RF with
cable, RF wireless and wireless mobility measureing device using 30 dental implants in human
dried cadaveric mandibles. The authors demonstrated that both RF with cable and RF wireless
seem to be suitable to detect peri-implant bone loss around implants. But wireless mobility
measureing device may not be suitable to detect the 1 mm peri-implant bone changes.
5. ISQ change pattern measured at different direction using magnetic RFA
Data from a conventional piezoelectric RFA are generally obtained with the transducer in
the buccolingual position, because the shape of the transducer restricts its orientation when
adjacent teeth remain. The measurement of the stiffness of the bone/implant complex in one
direction by the use of piezoelectric RFA reflects the stability of an implant only partially,
because implant–bone fusion occurs at 360° around a fixture and implant stability is a
general reflection of this fusion. According to studies that used piezoelectric RFA, the ISQ of
the mesiodistal(MD) measurement was 10 points higher than that of the buccolingual(BL)
measurement(Fischer, et al. 2008, Veltri, et al. 2007). Unlike piezoelectric RFA, magnetic
RFA(MentorTM: Ostell AB) is recommended to measure two ISQs, using the vibrations that
occur in the directions of the higher and lower resonance frequency as a basis(Sennerby &
Meredith 2008), because magnetic RFA can provide multi-directional measurements and it
is known that the orientation of the transducer (mesiodistal or buccolingual) may affect the
measurement of the implant stability quotient (ISQ). If the numerical difference of these two
values is more than three ISQ units, both of them are displayed simultaneously. To ensure
that both values are measured, the manufacturer of MentorTM recommends that the probe be
held perpendicular to the alveolar crest for one measurement, and in line with the crest for
the other measurement. However, it is not known whether the ISQs estimated using
MentorTM vary with the direction of measurement in the same way as estimates measured
using piezoelectric RFA. For this reason, the authors performed an randomized clinical trial
to determine whether it is necessary to take measurements in both the mesiodistal(MD) and
buccolingual(BL) directions in order to assess changes in bone–implant stiffness when such
measurements are made using magnetic RFA.
5.1 Study design, methods and materials
A prospective clinical trial was completed, in a total of 53 patients, on 71 non-submerged
dental implants that were inserted to replace the unilateral loss of mandibular molars. Two
non-submerged implant systems with the same diameter (4.1mm), length (10mm), and
collar height (2.8mm) were used in this clinical study. Standard Straumann® Dental
Implants (Institut Straumann AG, Basel, Switzerland) were used for 32 of the implants.
Osstem SSII Implants (Osstem Implants, Seoul, Republic of Korea) were used for the
remaining 39 implants. Mentor™ (Ostell AB, Göteborg, Sweden) was used for to make
magnetic RFA measurements. In addition, Type 4 Smartpeg™ (Osstell AB. Göteborg,
Sweden) pegs were used during magnetic RFA. The ISQs were measured during the
surgical procedure and at 4 and 10 weeks after surgery. Measurements were taken twice in
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each direction: in the buccolingual direction from the buccal side (BL) and in the mesiodistal
direction from the mesial side (MD). The mean of the two measurements in each direction
was regarded as the representative ISQ of that direction. The higher and lower values of the
buccolingual and mesiodistal ISQs were also classified separately. In other words, the ISQ of
each implant was estimated using four measures at each time: the ISQ measured from the
direction perpendicular to the alveolar crest on the BL; the ISQ from the direction parallel to
the alveolar crest on the MD; the ISQ showing the higher value of the BL and MD (MX); and
the ISQ showing the lower value of the BL and MD (MN). Discrepancies in ISQ were
calculated by subtracting the BL from the MD in each period. The variation in ISQ was
quantified by subtracting the MN from the MX during surgery; it was found to be the same
as the absolute value of the ISQ discrepancy. The implants tested were classified into two
groups: a group with variation in ISQ of three or more (3+Group) and a group with
variation of less than 3 (3-Group).
5.2 Result of the study
During the surgical procedure, the ISQ discrepancies measured from 2 different directions
were 0.36 to 1. Ten weeks later, the discrepancies had decreased to -0.14 to 0.42. Eight out of
the 53 implants were classified in the 3+Group, accounting for 15.1% of the total(Table 1).
The bone width at the insertion area was 6.89mm for the 3+Group and 6mm for the 3-Group
(P=0.171). The average age of the 3+Group was 51.88 years, whereas that of the 3-Group was
only 47.6 years. However, the difference was not statistically significant (P=0.398).
No differences were found between the BL and MD, but significant differences between MX
and MN were observed at every measurement point for each implant system. The average BL
during surgery showed a significant difference between the 3+Group and the 3-Group
(P=0.002). No significant differences were observed in the MD values (P=0.177). The average
MN during surgery showed a significant difference (P<0.001). In contrast, there were no
significant differences in the MX values (P=0.417)(Table 2, 3). The ISQs were compared
between the 3+Group and the 3-Group to determine whether there was a change in the values
over time. A significant difference between the two groups was observed for the MN values
(P=0.001). However, no significant differences were found for the MX values between the two
groups (P=0.597). With respect to the BL and MD values, a significant difference was found
between the two groups only for the BL value (P=0.001 for BL, P=0.392 for MD; Fig. 9).
5.3 Conclusion
The variation in ISQ obtained using magnetic RFA measurements from the two different
directions was lower than that reported using piezoelectric RFA. The mean of the
discrepancy in ISQ that was calculated from data obtained using magnetic RFA was <1
point. This showed that the discrepancy in ISQ was not skewed to the MD in such an
extreme manner as the discrepancy of 10 points found using piezoelectric RFA. With this
respect, two- directional measurement is not meaningful. However, our study demonstrated
the possibility of observing a different pattern of change between the higher and lower
values in a single implant. A significant difference was observed between the 3+Group and
the 3-Group in the lower value (MN) of the change in ISQ during the initial healing period.
This suggests that a longitudinal comparison of the higher and lower values may improve
the evaluation of implant stability, in comparison with the use of a single directional
measurement. This suggests that the follow-up observation of scale-based ISQ (lower and
higher) values may detect a significant change in the ISQ pattern more readily than the
direction-based observations (MD and BL).
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Implant Dentistry  A Rapidly Evolving Practice122
Variables ISQ variation P-value*
<3 ≥3
Implant based (N=71)
Implant number 60 11
Location 1
molar 30 6
2nd molar 30 5
Age (mean±SD) 47.00 ± 12.47 53.09 ± 10.27 0.123
Age
10-50 33 3 0.111
>50 27 8
Sex
male 37 7 1
female 23 4
Smoking
Yes 26 4 0.75
No 34 7
Width(mean±SD) † 6.93 ± 2.02 6.09 ± 0.30 0.12
Implant type
Straumann 27 5 1
SSII 33 6
Insertion depth (mean±SD) ‡
Proximal 1.81 ± 0.56 1.85 ± 0.86 0.844
Distal 2.10 ± 0.59 1.91 ± 0.84 0.34
Participant based (N =
53)
Participant number 45 8
Location
molar 20 4 0.771
2nd molar 25 4
Age (mean±SD)
Age
10-50 24 3 0.486
>50 21 5
Sex
male 28 6 0.583
female 17 2
Smoking
Yes 17 3 0.99
No 28 5
Width(mean±SD) † 6.89 ± 1.9 6 ± 0 0.171
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Implant type
Straumann 21 4 0.862
SSII 24 4
Insertion depth (mean±SD) ‡
Proximal 1.71 ± 0.53 2.03 ± 0.86 0.547
Distal 2.03 ± 0.6 2.13 ± 0.86 0.841
Data unit, except for continuous variables, are presented as the number. The units of age, width, and
insertion depth are year, mm, respectively.
*P-values were calculated by a χ2-test for nominal variables, and Mann-Whitney test for continuous for
continuous variables.
†Width was measured in the buccolingual direction using a microcompass, after implant insertion.
‡Insertion depth was checked by measuring the distance between the implant shoulders and the
alveolar bone using a UNC periodontal probe.
Table 1. Comparison of demographic data between the two groups of patients with implants
showing different levels of implant stability quotient (ISQ) variation during implant surgery
(Cited from Park et al, 2010)
Fig. 9. The comparison of the pattern of change in the implant stability quotient (ISQs)
obtained from the four measures from surgery to 10 weeks after surgery. 3+Group=the
group with ISQ variation of 3 or more. 3-Group=the group with ISQ variation of < 3. (a)
Pattern of change of minimum. (b) Pattern of change of maxilmum. (c)Pattern of change of
buccoligual. (d) Pattern of change of mesiodistal.
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ISQ ISQ
The difference of the
paired
P-value *
(mean ± SD) (mean ± SD) data (mean ± SD)
All implants ( N=53)
During surgery
BL† 76.01 ± 6.57 MD‡ 76.69 ± 6.26 0.71 ± 3.21 0.063
MX§ 77.2 ± 6.13 MN
∥
75.51 ± 6.6 1.72 ± 2.79 <0.001
At post-operative
week 4
BL 77.09 ± 5.59 MD 77.28 ± 5.58 0.19 ± 1.82 0.469
MX 77.72 ± 5.52 MN 76.3 ± 5.6 1.11 ± 1.46 <0.001
At post-operative
week 10
BL 79.65 ± 3.98 MD 79.69 ±3.97 0.01 ± 1.76 0.671
MX 74.56 ± 6.19 MN 73.04 ± 6.2 1.58 ± 2.47 <0.001
Straumann (N=25)
During surgery
BL 73.28 ± 6.38 MD 74.32 ± 6.02 1.10 ± 2.72 0.056
MX 74.56 ± 6.19 MN 73.04 ± 6.2 1.58 ± 2.47 <0.001
At post-operative
week 4
BL 74.8 ± 4.52 MD 75.22 ± 4.28 0.42 ± 1.48 0.199
MX 75.54 ±4.23 MN 74.48 ±4.54 1.06 ± 1.1 <0.001
At post-operative
week 10
BL 78.1 ± 3.65 MD 78.34 ± 3.76 0.24 ± 1.98 0.732
MX 78.78 ± 3.51 MN 77.66 ± 3.8 1.12 ± 1.64 0.001
SSII (N=28)
During surgery
BL 78.45 ± 5.82 MD 78.8 ± 5.78 0.36 ± 3.6 0.523
MX 79.55 ± 5.17 MN 77.71 ± 6.24 4.84 ± 3.09 <0.001
At post-operative
week 4
www.intechopen.com
Implant Stability - Measuring Devices and Randomized Clinical Trial
for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 125
BL 79.14 ± 5.72 MD 79.13 ± 6.02 -0.02 ± 2.07 0.861
MX 79.66 ± 5.86 MN 78.5 ± 5.87 1.16 ± 1.74 0.001
At post-operative
week 10
BL 81.04 ± 3.8 MD 80.89 ± 3.82 -0.14 ± 1.54 0.71
MX 81.43 ± 3.69 MN 80.5 ±3.88 0.93 ± 1.23 0.001
*P- value was calculated using a Wilcoxon signed ranks test between BL and MD, or between MX and
MN
†BL is the ISQ measured from the direction perpendicular to the alveolar crest at the buccal side
‡MD is the ISQ measured from the direction parallel to the alveolar crest at the mesial side
§MX is the ISQ of the direction that showed the higher value between BL and MD
∥
MN is the ISQ of the direction which show the lower value between BL and MD
Table 2. Comparison of four different measures of implant stability quotient (ISQ) (Cited
from Park et al, 2010)
Period Mode ISQ Variation P-value †
< 3 (N=45) ≥ 3 (N=8)
ISQ
(mean ± SD)
P-value* ISQ
(mean ±
SD)
P-value*
All implants
(N=53)
During surgery BL 77.08 ± 5.97 0.567 70 ± 6.95 0.161 0.002
MD 77.17 ± 5.8 73.94±8.48 0.177
MX 77.48 ± 5.85 <0.001 75.56±7.97 0.012 0.417
MN 76.78 ± 5.9 68.38±6 <0.001
At post-operative BL 77.23 ± 4.81 0.663 76.31±9.26 0.553 0.650
week 4 MD 77.4 ± 4.95 76.63±8.75 0.722
MX 77.78 ± 4.86 <0.001 77.38±8.81 0.018 0.862
MN 76.79 ± 4.87 75.56±9.1 0.551
At post-operative BL 79.66 ± 3.99 0.471 79.63±4.14 0.553 0.639
week 10 MD 79.78 ± 3.83 79.19±4.93 0.731
MX 80.16 ± 3.81 <0.001 79.86±3.93 0.018 0.866
MN 79.28 ± 3.97 78.5±4.8 0.645
*P- value were calculated using a Wilcoxon signed ranks test between BL and MD, or between MX and
MN in each group based on ISQ variation
† P- value were calculated using a two-way analysis of variance between the two groups based on ISQ
variation.
Table 3. Comparison of four different measures of implant stability quotient (ISQ) between
the two implant groups based on the level of ISQ variation during implant surgery (Cited
from Park et al, 2010)
www.intechopen.com
Implant Dentistry  A Rapidly Evolving Practice126
6. Acknowledgement
This work was supported by Seoul Research & Business Development (PA100004), granted
by Seoul Metropolitan Government, Republic of Korea.
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for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 127
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(2007) Evaluation of two different resonance frequency devices to detect implant
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www.intechopen.com
Implant Dentistry - A Rapidly Evolving Practice
Edited by Prof. Ilser Turkyilmaz
ISBN 978-953-307-658-4
Hard cover, 544 pages
Publisher InTech
Published online 29, August, 2011
Published in print edition August, 2011
InTech Europe
University Campus STeP Ri
Slavka Krautzeka 83/A
51000 Rijeka, Croatia
Phone: +385 (51) 770 447
Fax: +385 (51) 686 166
www.intechopen.com
InTech China
Unit 405, Office Block, Hotel Equatorial Shanghai
No.65, Yan An Road (West), Shanghai, 200040, China
Phone: +86-21-62489820
Fax: +86-21-62489821
Implant dentistry has come a long way since Dr. Branemark introduced the osseointegration concept with
endosseous implants. The use of dental implants has increased exponentially in the last three decades. As
implant treatment became more predictable, the benefits of therapy became evident. The demand for dental
implants has fueled a rapid expansion of the market. Presently, general dentists and a variety of specialists
offer implants as a solution to partial and complete edentulism. Implant dentistry continues to evolve and
expand with the development of new surgical and prosthodontic techniques. The aim of Implant Dentistry - A
Rapidly Evolving Practice, is to provide a comtemporary clinic resource for dentists who want to replace
missing teeth with dental implants. It is a text that relates one chapter to every other chapter and integrates
common threads among science, clinical experience and future concepts. This book consists of 23 chapters
divided into five sections. We believe that, Implant Dentistry: A Rapidly Evolving Practice, will be a valuable
source for dental students, post-graduate residents, general dentists and specialists who want to know more
about dental implants.
How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:
Jong-Chul Park, Jung-Woo Lee, Soung-Min Kim and Jong-Ho Lee (2011). Implant Stability - Measuring
Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions
by Magnetic RFA, Implant Dentistry - A Rapidly Evolving Practice, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-
307-658-4, InTech, Available from: http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving-
practice/implant-stability-measuring-devices-and-randomized-clinical-trial-for-isq-value-change-pattern-measu

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Implant stability intech

  • 1. 5 Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA Jong-Chul Park, Jung-Woo Lee, Soung-Min Kim and Jong-Ho Lee Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University, Seoul, Korea 1. Introduction Implant stability plays a critical role for successful osseointegration, which has been viewed as a direct structural and functional connection existing between bone and the surface of a load-carrying implant(Bränemark, et al. 1977, Sennerby & Roos 1998). Achievement and maintenance of implant stability are prerequisites for successful clinical outcome(Sennerby & Meredith 2008). Therefore, measuring the implant stability is an important method for evaluating the success of an implant. Implant stability is achieved at two different stages: primary and secondary. Primary stability of an implant comes from mechanical engagement with cortical bone. It is affected by the quantity and quality of bone that the implant is inserted into, surgical procedure, length, diameter, and form of the implant(Meredith 1998). Secondary stability is developed from regeneration and remodeling of the bone and tissue around the implant after insertion but is affected by the primary stability, bone formation and remodeling(Sennerby & Roos 1998). The time of functional loading is dependent upon the secondary stability. It is, therefore, of an utmost importance to be able to quantify implant stability at various time points and to project a long term prognosis based on the measured implant stability(Atsumi, et al. 2007). 2. Measuring analyses of implant stability Presently, various diagnostic analyses have been suggested to define implant stability. Primary implant stability can be measured by either a destructive or a non-destructive method. Histomorphologic research, tensional test, push-out/pull-out test and removal torque test are classified as destructive methods. Non-destructive methods include percussion test, radiography, cutting torque test while placing implants, Periotest®(Siemens AG, Benshein, Germany), and resonance frequency analysis(RFA)(Meredith 1998). www.intechopen.com
  • 2. Implant Dentistry  A Rapidly Evolving Practice112 2.1 Tensional test The interfacial tensile strength was originally measured by detaching the implant plate from the supporting bone(Kitsugi, et al. 1996). Bränemark later modified this technique by applying the lateral load to the implant fixture(Bränemark, et al. 1998). However, they also addressed the difficulties of translating the test results to any area- independent mechanical properties(Chang, et al. 2010)(Fig. 1a). 2.2 Histomorphometric analysis Histomorphometric analysis is obtained by calculating the peri-implant bone quantity and bone-implant contact(BIC) from a dyed specimen of the implant and peri-implant bone. Accurate measurement is an advantage, but due to the invasive and destructive procedure, it is not appropriate for long-term studies. It is used in non-clinical studies and experiments. 2.2 Push-out/pull-out test The ‘push-out’ or ‘pull-out’ test is the most commonly used approach to investigate the healing capabilities at the bone implant interface(Brunski, et al. 2000). In the typical push- out or pull-out test, a cylinder-type implant is placed transcortically or intramedullarly in Fig. 1. Stability analyses for oral implant osseointegration from Chang, P. C., Lang, N. P. & Giannobile, W. V. (2010). “Evaluation of functional dynamics during osseointegration and regeneration associated with oral implants.” Clinical Oral Implants Research 21: 1-12. (a) tensional test, (b) push-out test, (c) pull-out test, (d) insertional/removal torque test, (e) Periotest, and (e) resonance frequency analysis (RFA). www.intechopen.com
  • 3. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 113 bone structures and then removed by applying a force parallel to the interface. The maximum load capability (or failure load) is defined as the maximum force on the force– displacement plot, and the interfacial stiffness is visualized as the slope of a tangent approximately at the linear region of the force–displacement curve before breakpoint (Brunski, et al. 2000, Lutolf, et al. 2003). Therefore, the general loading capacity of the interface (or interfacial shear strength) can be measured by dividing the maximum force by the area of implant in contact with the host bone(Berzins, et al. 1997). However, the push-out and pull-out tests are only applicable for non-threaded cylinder type implants, whereas most of clinically available fixtures are of threaded design, and their interfacial failures are solely dependent on shear stress without any consideration for either tensile or compressive stresses(Brunski, et al. 2000, Chang, et al. 2010)(Fig. 1b-c). 2.3 Removal torque analysis Application of a reverse or unscrewing torque has also been proposed for the assessment of implant stability at the time of abutment connection(Sullivan, et al. 1996), however, implant surface in the process of osseointegration may fracture under the applied torque stress(Ivanoff, et al. 1997)(Fig.1d). 2.4 Percussion test The test is carried out by a simple percussion with the handle of a dental instrument on the implant abutment and listening to the resulting sound. However, this method may be subjective according to the examiner and give inaccurate measurements for implants because of the high rigidity of implants and the lack of periodontal ligaments. 2.5 Insertion torque measurement Insertion torque values have been used to measure the bone quality in various parts of the jaw during implant placement(O'Sullivan, et al. 2004). Insertion torque alone may be used as an independent stability measurement, but it may also act as a variable, affecting implant stability. In a different light, insertion torque is a mechanical parameter generally affected by surgical procedure, implant design and bone quality at implant site(Beer, et al. 2003). However, it cannot assess the secondary stability by new bone formation and remodeling around the implant. So it cannot collect longitudinal data to assess implant stability change after placement. Also, an increase in insertion torque may signify an increase in primary stability, but maximum insertion torque is produced by the pressure of implant neck on the dense cortical bone of the alveolus. Furthermore, it has been reported that if maximum insertion torque doesn’t signify increased general bone density, it may indicate the insertion torque itself during tapping (Calandriello, et al. 2003)(Fig.1d). 2.6 Radiography Radiography provides useful information for evaluating the quantity and quality of bone in the area for an implant before placing the fixture. It is also helpful in predicting implant stability by observing the process of osseointegration or peri-implant lesions. However, there is a limitation in image resolution and standardized X-rays are difficult to achieve due to the distortion of images, making quantitative measurements more challenging. In addition, it is difficult to perceive changes in the bone structures and morphology of the implant-bone interface unless over 30% bone loss occurs. Although the accuracy of the www.intechopen.com
  • 4. Implant Dentistry  A Rapidly Evolving Practice114 diagnosis is low, radiography is the major method used clinically to evaluate osseointegration and implant stability because of its convenience. (Albrektsson, et al. 1986). 2.7 Periotest® Periotest® (Siemens AG, Benshein, Germany) was originally devised by Dr. Schulte to measure tooth mobility(Fig.2). Teerlinck, et al.(1991) used this method to overcome destructive methods in measuring the implant stability. Periotest® evaluates the damping capacity of the periodontium. It is designed to identify the damping capacity and the stiffness of the natural tooth or implant by measuring the contact time of an electronically driven and electronically monitored rod after percussing the test surface. Periotest value(PTV) is marked from -8(low mobility) to +50(high mobility). PTV of -8 to -6 is considered good stability. Periotest® can measure all surfaces such as the abutment or prosthesis, but the rod must make contact at a correct angle and distance. If the perpendicular contact angle is larger than 20 degrees, or if the parallel contact angle is larger than 4 degrees, the measured value is invalid. Also, the rod and the test surface must maintain 0.6-2.0mm distance and if the distance is over 5mm, the measured value may be insignificant. (Ito, et al. 2008, Schulte 1988). Periotest® has limited clinical use since it cannot measure the mesiodistal mobility and the position and angle of the rod affects the measured value. Also, it cannot detect the small changes in the implant- bone surface. The most failing point of this method is that the percussing force on the implant may deteriorate the stability in poor initial stability implants. (a) (b) Fig. 2. Periotest® (Siemens AG, Benshein, Germany) measures tooth mobility and implant stability by periotest value(PTV). (a) Periotest®, (B) Periotest®M. 2.8 Resonance Frequency Analysis(RFA) In 1998, Meredith suggested a non-invasive method of analyzing peri-implant bone by connecting an adapter to an implant in an animal study. The experimented resonance frequency analysis system was commercially produced as OsstellTM (Osstell AB, Göteborg, Sweden). A measurement of OsstellTM is displayed as implant stability quotient(ISQ) from 1 to 100, where 100 signifies the highest implant stability. OsstellTM was later followed by OsstellTM Mentor, and OsstellTM ISQ. www.intechopen.com
  • 5. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 115 3. RFA principle and application 3.1 Introduction Meredith et al.(1996) reported the use of resonance frequency analyzer to evaluate implant stability by applying architectural engineering, and proved in early in vitro test the ability of the device in evaluating the stiffness change of the surface. RFA uses the principle of when a frequency of audibility range is repeatedly vibrated onto an implant, the stronger the bone- implant surface, resonance occurs in a higher frequency. The first commercial product of the resonance frequency analyzer(RFA) was OsstellTM(Osstell AB, Göteborg, Sweden)(Fig.3), followed by OsstellTM Mentor and recently OsstellTM ISQ was introduced. OsstellTM uses electronic technology and other devices(OsstellTM Mentor, OsstellTM ISQ) use magnetic technology (Fig.5). (a) (b) Fig. 3. Pictures showing the first commercial products of resonance frequency analyzer. (a) the OsstellTM and (b) the application of the OsstellTM electronic transducer to the implant.(The figure and illustration are cited with permission from Osstell website, www.osstell.com, April, 2011) 3.2 Electronic technology resonance frequency analyzer(Osstell TM ) The primary model OsstellTM produces alternating sine waves in a specific frequency range by uniform amplitude and makes the transducer connected to the implant or abutment vibrate under 1mm like an electronic tuning fork. A cantilever small beam is connected to the transducer and on this beam, 2 piezo-ceramic elements are attached. (Fig.3,4). One of them receives the signal and vibrates the transducer, and the other passes this vibration to the resonance frequency analyzer. Values on the monitor are displayed from 0-100 so that it can be conveniently used clinically. The value of 100 signify the highest stability state. Generally ISQ values for successfully integrated implants are reported from 57 to 82. These values can be displayed by graphs on the computer monitor or be expressed by values between 4500-8500Hz. The obtained output can be calculated by the equation below. = α EI ρl www.intechopen.com
  • 6. Implant Dentistry  A Rapidly Evolving Practice116 is the RF of the beam, l is the effective vibration length of the beam, E is the Young`s modulus, I is the moment of inertia, ρ is the mass, α the constant that increases as peri- implant bone density increases. Therefore, when osseointegration is achieved, RF increases since α value increases. ‘l’ signifies the length of implant above the bone. So as bone is resorbed, this value increases and thus RF decreases. In other words, ISQ is affected by the effective implant length, type of bone at implant site and bone density(Huang, et al. 2003, Huang, et al. 2003, Meredith, et al. 1996). Fig. 4. Picture showing the principle of electronic resonance frequency analyzer. (The figure and illustration are cited from Osstell website, www.osstell.com, April, 2011) 3.3 Magnetic technology resonance frequency analyzer(Osstell TM Mentor, Osstell TM ISQ) Resonance frequency between 3.5 KHz and 8.5 KHz formed from the magnetic field is converted into ISQ values by Osstell MentorTM(Fig. 5, 6). The transducer of Osstell MentorTM (a) (b) Fig. 5. Osstell MentorTM and Osstell ISQTM , both of devices measure ISQs by the magnetic technology. (The pictures are cited from Osstell website, www.osstell.com, April, 2011) www.intechopen.com
  • 7. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 117 (a) (b) Fig. 6. Principle of the Osstell MentorTM. Magnetic peg(Smart pegTM) works like a tuning fork. Red arrow is the Smart pegTM. (The figure and illustration are cited from Osstell website, www.osstell.com, April, 2011) has a magnetic peg on the top and is fixed to the implant fixture or abutment by a screw below. When magnetic resonance frequency is released from the probe, the magnetic peg is activated. The activated peg starts to vibrate, and the magnet induces electric volt into the probe coil and the electric volt is sampled by the magnetic resonance frequency analyzer (Fig. 6). The values are expressed as numbers between 1–100 in ISQ as OsstellTM (Valderrama, et al. 2007). The device is relatively expensive, and each implant system requires the respective transducer for OsstellTM and magnetic peg for Osstell MentorTM. The restricted use of the transducer and the magnetic peg is a great disadvantage. Also, evaluation is impossible in a prosthesis state or when the magnetic peg is damaged or when in contact with the soft tissue. Therefore, when using Osstell MentorTM, the Smart pegTM must maintain a distance of approximately 1-3 mm, angle of 90 degrees, and 3 mm above the soft tissue, otherwise the measured value may be affected (Fig. 7). Valderrama et al.(2007) reported in a study experimenting the correlation between OsstellTM and Osstell MentorTM that the two devices had high significant correlation. 3.4 Influencing factors of Implant Stability Quotient(ISQ) In many literature, it has been reported that ISQ is affected by implant diameter, surface, form, bone contact ratio, implant site, implant system, surgical procedure, bone quality and bone height (Atsumi, et al. 2007). RFA is determined by the changes in the interface stiffness, and it is affected in three aspects. First, bone-implant surface stiffness affects RFA and it increases through bone healing and remodeling. Secondly, the stiffness of bone itself, and bone density as well as the ratio of cortical and cancellous bone affects RFA. Finally, the stiffness of implant components can acts as a variable and it is affected by the interlocking structures, and the composing elements of the materials. Bone and implant surface stiffness may be affected by using a small-diameter final drill, changes in surgical techniques such as www.intechopen.com
  • 8. Implant Dentistry  A Rapidly Evolving Practice118 (a) (b) (c) Fig. 7. Application of magnetic RFA(OsstellTM Mentor) after immediate implant installation. The manufacturer recommends that the probe be held perpendicular to the alveolar crest(a) for the first measurement, and in line with the crest for the other measurement(b). And the Smart pegTM must maintain a distance of approximately 1-3 mm, angle of 90 degrees, and 3 mm above the soft tissue(c). bone compaction technique, self-tapping design implants and wide tapered implants, but not by implant length. In a histomorphologic study, it was reported that the resonance frequency value is highly correlated with the bone-implant contact amount(Friberg, et al. 1999, Meredith, et al. 1997). There are reports showing a correlation between RFA and the histomorphometric analysis, and other reports claim that the correlation between the bone density and ISQ is not significant. Therefore RFA signifies the bone anchorage of implants but the relation of RFA and bone structure is not yet clear (Alsaadi, et al. 2007, Huwiler, et al. 2007, Rasmusson, et al. 1998, Zhou, et al. 2008). Such diverse results showed RFA value decreases during the first 2 weeks after implant placement, and this change can be related to early bone healing such as biological change and marginal alveolar bone resorption. Bone remodeling reduces primary bone contact and in the early stage after implant placement, the formation of bony callus and increasing lamellar bone in the cortical bone causes major changes in bone density. Thus, in the healing process, primary bone contact decreases and secondary bone contact increases (Barewal, et al. 2003, Zhou, et al. 2008). Also, the 3– dimensional implant-bone contact is displayed 2 dimensionally in the histological sample and BIC has possibility of inaccuracy to signify bone-implant contact (Perrotti, et al. 2010). The relationship of bone structure and RFA is not fully understood. Since primary stability is affected by bone volume or bone trabecula structure as well as cortical bone thickness and density, the effect of bone quality on implant stability cannot be explained by bone microstructure alone (Huwiler, et al. 2007). www.intechopen.com
  • 9. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 119 4. Which device is more accurate to determine the stability of dental implants - recent literature review There are two groups of non-invasice devices. One is the RFA analyzer group and the other is the mobility measuring device. The OsstellTM is the commercial name of the RFA analyzer group. This device has a cable which is linked a electronic transducer (Fig. 3). The later version of the OsstellTM is the OssetellTM mentor which has no cable and uses of magnetic resonance frequency (Fig. 5). Periotest® is the commercial name of the mobility measuring device. Periotest® M is the newer device of the Periotest® and it is a wireless version (Fig. 2). 4.1 PTV and ISQ Many studies have indicated the presence of correlation between PTVs(the values of Periotest®) and ISQ (the values of OsstellTM and OssetellTM mentor). However, the correlation of implant stability and each value are still the controversial issue. Aparicio et al. (2006) presentd that the validity and relevance of both ISQ and PTVs for clinical use have to be questioned in their review article. Lachmann et al. (2006) compared OsstellTM and Periotest® by in vitro study and demonstrated that both methods are useful in the evaluation of implant stability but the OsstellTM was more precise than the Periotest® to determine the actual dental implant stability at peri-implant defects. Zix et al. (2008) studied with controlled clinical trial and concluded that Periotest® values appear to be more susceptible to clinical conditions and the OsstellTM instrument seemed to be more precise than the Periotest®. Winter et al.(2010) investigated the correlation between the two devices through the finite element study and demonstrated that Periotest® values had only good correlation with implant stability in case when there’s no bone loss. Oh et al.(2009) reported that the Periotest® and OsstellTM Mentor were useful and comparably reliable, showing a strong association with each other in assessing implant stability in their experimental study. In summarizing the literature, it is generally accepted that the RFA is more accurate than the mobility measuring device, but the mobility measuring device is more convenient in clinical usage than RFA (Fig.8). (a) (b) Fig. 8. Application of Periotest® M. This device can measure the implant stability and mobility of natural teeth without special device, for example magnetic peg. (a) is the application of Periotest® M to natural tooth. (b) is the measurement of implant stability during follow-up period without implant crown removal. www.intechopen.com
  • 10. Implant Dentistry  A Rapidly Evolving Practice120 4.2 Electronic resonance frequency and magnetic resonance frequency Valderrama et al.(2007) performed clinical research using electronic- and magnetic-based devices on 34 non-submerged titanium dental implants in 17 patients and demonstrated that changes in implant stability measured with the magnetic device correlate well with those found with the electronic device. Both devices confirmed the initial decreases in implant stability that occur following placement and identified an increase in stability during the first 6 weeks of functional loading. Tozum et al.(2010) compared three devices which are RF with cable, RF wireless and wireless mobility measureing device using 30 dental implants in human dried cadaveric mandibles. The authors demonstrated that both RF with cable and RF wireless seem to be suitable to detect peri-implant bone loss around implants. But wireless mobility measureing device may not be suitable to detect the 1 mm peri-implant bone changes. 5. ISQ change pattern measured at different direction using magnetic RFA Data from a conventional piezoelectric RFA are generally obtained with the transducer in the buccolingual position, because the shape of the transducer restricts its orientation when adjacent teeth remain. The measurement of the stiffness of the bone/implant complex in one direction by the use of piezoelectric RFA reflects the stability of an implant only partially, because implant–bone fusion occurs at 360° around a fixture and implant stability is a general reflection of this fusion. According to studies that used piezoelectric RFA, the ISQ of the mesiodistal(MD) measurement was 10 points higher than that of the buccolingual(BL) measurement(Fischer, et al. 2008, Veltri, et al. 2007). Unlike piezoelectric RFA, magnetic RFA(MentorTM: Ostell AB) is recommended to measure two ISQs, using the vibrations that occur in the directions of the higher and lower resonance frequency as a basis(Sennerby & Meredith 2008), because magnetic RFA can provide multi-directional measurements and it is known that the orientation of the transducer (mesiodistal or buccolingual) may affect the measurement of the implant stability quotient (ISQ). If the numerical difference of these two values is more than three ISQ units, both of them are displayed simultaneously. To ensure that both values are measured, the manufacturer of MentorTM recommends that the probe be held perpendicular to the alveolar crest for one measurement, and in line with the crest for the other measurement. However, it is not known whether the ISQs estimated using MentorTM vary with the direction of measurement in the same way as estimates measured using piezoelectric RFA. For this reason, the authors performed an randomized clinical trial to determine whether it is necessary to take measurements in both the mesiodistal(MD) and buccolingual(BL) directions in order to assess changes in bone–implant stiffness when such measurements are made using magnetic RFA. 5.1 Study design, methods and materials A prospective clinical trial was completed, in a total of 53 patients, on 71 non-submerged dental implants that were inserted to replace the unilateral loss of mandibular molars. Two non-submerged implant systems with the same diameter (4.1mm), length (10mm), and collar height (2.8mm) were used in this clinical study. Standard Straumann® Dental Implants (Institut Straumann AG, Basel, Switzerland) were used for 32 of the implants. Osstem SSII Implants (Osstem Implants, Seoul, Republic of Korea) were used for the remaining 39 implants. Mentor™ (Ostell AB, Göteborg, Sweden) was used for to make magnetic RFA measurements. In addition, Type 4 Smartpeg™ (Osstell AB. Göteborg, Sweden) pegs were used during magnetic RFA. The ISQs were measured during the surgical procedure and at 4 and 10 weeks after surgery. Measurements were taken twice in www.intechopen.com
  • 11. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 121 each direction: in the buccolingual direction from the buccal side (BL) and in the mesiodistal direction from the mesial side (MD). The mean of the two measurements in each direction was regarded as the representative ISQ of that direction. The higher and lower values of the buccolingual and mesiodistal ISQs were also classified separately. In other words, the ISQ of each implant was estimated using four measures at each time: the ISQ measured from the direction perpendicular to the alveolar crest on the BL; the ISQ from the direction parallel to the alveolar crest on the MD; the ISQ showing the higher value of the BL and MD (MX); and the ISQ showing the lower value of the BL and MD (MN). Discrepancies in ISQ were calculated by subtracting the BL from the MD in each period. The variation in ISQ was quantified by subtracting the MN from the MX during surgery; it was found to be the same as the absolute value of the ISQ discrepancy. The implants tested were classified into two groups: a group with variation in ISQ of three or more (3+Group) and a group with variation of less than 3 (3-Group). 5.2 Result of the study During the surgical procedure, the ISQ discrepancies measured from 2 different directions were 0.36 to 1. Ten weeks later, the discrepancies had decreased to -0.14 to 0.42. Eight out of the 53 implants were classified in the 3+Group, accounting for 15.1% of the total(Table 1). The bone width at the insertion area was 6.89mm for the 3+Group and 6mm for the 3-Group (P=0.171). The average age of the 3+Group was 51.88 years, whereas that of the 3-Group was only 47.6 years. However, the difference was not statistically significant (P=0.398). No differences were found between the BL and MD, but significant differences between MX and MN were observed at every measurement point for each implant system. The average BL during surgery showed a significant difference between the 3+Group and the 3-Group (P=0.002). No significant differences were observed in the MD values (P=0.177). The average MN during surgery showed a significant difference (P<0.001). In contrast, there were no significant differences in the MX values (P=0.417)(Table 2, 3). The ISQs were compared between the 3+Group and the 3-Group to determine whether there was a change in the values over time. A significant difference between the two groups was observed for the MN values (P=0.001). However, no significant differences were found for the MX values between the two groups (P=0.597). With respect to the BL and MD values, a significant difference was found between the two groups only for the BL value (P=0.001 for BL, P=0.392 for MD; Fig. 9). 5.3 Conclusion The variation in ISQ obtained using magnetic RFA measurements from the two different directions was lower than that reported using piezoelectric RFA. The mean of the discrepancy in ISQ that was calculated from data obtained using magnetic RFA was <1 point. This showed that the discrepancy in ISQ was not skewed to the MD in such an extreme manner as the discrepancy of 10 points found using piezoelectric RFA. With this respect, two- directional measurement is not meaningful. However, our study demonstrated the possibility of observing a different pattern of change between the higher and lower values in a single implant. A significant difference was observed between the 3+Group and the 3-Group in the lower value (MN) of the change in ISQ during the initial healing period. This suggests that a longitudinal comparison of the higher and lower values may improve the evaluation of implant stability, in comparison with the use of a single directional measurement. This suggests that the follow-up observation of scale-based ISQ (lower and higher) values may detect a significant change in the ISQ pattern more readily than the direction-based observations (MD and BL). www.intechopen.com
  • 12. Implant Dentistry  A Rapidly Evolving Practice122 Variables ISQ variation P-value* <3 ≥3 Implant based (N=71) Implant number 60 11 Location 1 molar 30 6 2nd molar 30 5 Age (mean±SD) 47.00 ± 12.47 53.09 ± 10.27 0.123 Age 10-50 33 3 0.111 >50 27 8 Sex male 37 7 1 female 23 4 Smoking Yes 26 4 0.75 No 34 7 Width(mean±SD) † 6.93 ± 2.02 6.09 ± 0.30 0.12 Implant type Straumann 27 5 1 SSII 33 6 Insertion depth (mean±SD) ‡ Proximal 1.81 ± 0.56 1.85 ± 0.86 0.844 Distal 2.10 ± 0.59 1.91 ± 0.84 0.34 Participant based (N = 53) Participant number 45 8 Location molar 20 4 0.771 2nd molar 25 4 Age (mean±SD) Age 10-50 24 3 0.486 >50 21 5 Sex male 28 6 0.583 female 17 2 Smoking Yes 17 3 0.99 No 28 5 Width(mean±SD) † 6.89 ± 1.9 6 ± 0 0.171 www.intechopen.com
  • 13. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 123 Implant type Straumann 21 4 0.862 SSII 24 4 Insertion depth (mean±SD) ‡ Proximal 1.71 ± 0.53 2.03 ± 0.86 0.547 Distal 2.03 ± 0.6 2.13 ± 0.86 0.841 Data unit, except for continuous variables, are presented as the number. The units of age, width, and insertion depth are year, mm, respectively. *P-values were calculated by a χ2-test for nominal variables, and Mann-Whitney test for continuous for continuous variables. †Width was measured in the buccolingual direction using a microcompass, after implant insertion. ‡Insertion depth was checked by measuring the distance between the implant shoulders and the alveolar bone using a UNC periodontal probe. Table 1. Comparison of demographic data between the two groups of patients with implants showing different levels of implant stability quotient (ISQ) variation during implant surgery (Cited from Park et al, 2010) Fig. 9. The comparison of the pattern of change in the implant stability quotient (ISQs) obtained from the four measures from surgery to 10 weeks after surgery. 3+Group=the group with ISQ variation of 3 or more. 3-Group=the group with ISQ variation of < 3. (a) Pattern of change of minimum. (b) Pattern of change of maxilmum. (c)Pattern of change of buccoligual. (d) Pattern of change of mesiodistal. www.intechopen.com
  • 14. Implant Dentistry  A Rapidly Evolving Practice124 ISQ ISQ The difference of the paired P-value * (mean ± SD) (mean ± SD) data (mean ± SD) All implants ( N=53) During surgery BL† 76.01 ± 6.57 MD‡ 76.69 ± 6.26 0.71 ± 3.21 0.063 MX§ 77.2 ± 6.13 MN ∥ 75.51 ± 6.6 1.72 ± 2.79 <0.001 At post-operative week 4 BL 77.09 ± 5.59 MD 77.28 ± 5.58 0.19 ± 1.82 0.469 MX 77.72 ± 5.52 MN 76.3 ± 5.6 1.11 ± 1.46 <0.001 At post-operative week 10 BL 79.65 ± 3.98 MD 79.69 ±3.97 0.01 ± 1.76 0.671 MX 74.56 ± 6.19 MN 73.04 ± 6.2 1.58 ± 2.47 <0.001 Straumann (N=25) During surgery BL 73.28 ± 6.38 MD 74.32 ± 6.02 1.10 ± 2.72 0.056 MX 74.56 ± 6.19 MN 73.04 ± 6.2 1.58 ± 2.47 <0.001 At post-operative week 4 BL 74.8 ± 4.52 MD 75.22 ± 4.28 0.42 ± 1.48 0.199 MX 75.54 ±4.23 MN 74.48 ±4.54 1.06 ± 1.1 <0.001 At post-operative week 10 BL 78.1 ± 3.65 MD 78.34 ± 3.76 0.24 ± 1.98 0.732 MX 78.78 ± 3.51 MN 77.66 ± 3.8 1.12 ± 1.64 0.001 SSII (N=28) During surgery BL 78.45 ± 5.82 MD 78.8 ± 5.78 0.36 ± 3.6 0.523 MX 79.55 ± 5.17 MN 77.71 ± 6.24 4.84 ± 3.09 <0.001 At post-operative week 4 www.intechopen.com
  • 15. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 125 BL 79.14 ± 5.72 MD 79.13 ± 6.02 -0.02 ± 2.07 0.861 MX 79.66 ± 5.86 MN 78.5 ± 5.87 1.16 ± 1.74 0.001 At post-operative week 10 BL 81.04 ± 3.8 MD 80.89 ± 3.82 -0.14 ± 1.54 0.71 MX 81.43 ± 3.69 MN 80.5 ±3.88 0.93 ± 1.23 0.001 *P- value was calculated using a Wilcoxon signed ranks test between BL and MD, or between MX and MN †BL is the ISQ measured from the direction perpendicular to the alveolar crest at the buccal side ‡MD is the ISQ measured from the direction parallel to the alveolar crest at the mesial side §MX is the ISQ of the direction that showed the higher value between BL and MD ∥ MN is the ISQ of the direction which show the lower value between BL and MD Table 2. Comparison of four different measures of implant stability quotient (ISQ) (Cited from Park et al, 2010) Period Mode ISQ Variation P-value † < 3 (N=45) ≥ 3 (N=8) ISQ (mean ± SD) P-value* ISQ (mean ± SD) P-value* All implants (N=53) During surgery BL 77.08 ± 5.97 0.567 70 ± 6.95 0.161 0.002 MD 77.17 ± 5.8 73.94±8.48 0.177 MX 77.48 ± 5.85 <0.001 75.56±7.97 0.012 0.417 MN 76.78 ± 5.9 68.38±6 <0.001 At post-operative BL 77.23 ± 4.81 0.663 76.31±9.26 0.553 0.650 week 4 MD 77.4 ± 4.95 76.63±8.75 0.722 MX 77.78 ± 4.86 <0.001 77.38±8.81 0.018 0.862 MN 76.79 ± 4.87 75.56±9.1 0.551 At post-operative BL 79.66 ± 3.99 0.471 79.63±4.14 0.553 0.639 week 10 MD 79.78 ± 3.83 79.19±4.93 0.731 MX 80.16 ± 3.81 <0.001 79.86±3.93 0.018 0.866 MN 79.28 ± 3.97 78.5±4.8 0.645 *P- value were calculated using a Wilcoxon signed ranks test between BL and MD, or between MX and MN in each group based on ISQ variation † P- value were calculated using a two-way analysis of variance between the two groups based on ISQ variation. Table 3. Comparison of four different measures of implant stability quotient (ISQ) between the two implant groups based on the level of ISQ variation during implant surgery (Cited from Park et al, 2010) www.intechopen.com
  • 16. Implant Dentistry  A Rapidly Evolving Practice126 6. Acknowledgement This work was supported by Seoul Research & Business Development (PA100004), granted by Seoul Metropolitan Government, Republic of Korea. 7. References Albrektsson, T., Zarb, G., Worthington, P. & Eriksson, A. R. (1986) The long-term efficacy of currently used dental implants: A review and proposed criteria of success. The International journal of oral & maxillofacial implants 1: 11-25. Alsaadi, G., Quirynen, M., Michiels, K. & van Steenberghe, D. (2007) A biomechanical assessment of the relation between the oral implant stability at insertion and subjective bone quality assessment. J Clin Periodontol 34: 359-366. Aparicio, C., Lang, N. P. & Rangert, B. (2006) Validity and clinical significance of biomechanical testing of implant/bone interface. Clinical oral implants research 17 Suppl 2: 2-7. Atsumi, M., Park, S. H. & Wang, H. L. (2007) Methods used to assess implant stability: Current status. The International journal of oral & maxillofacial implants 22: 743-754. Barewal, R. M., Oates, T. W., Meredith, N. & Cochran, D. L. (2003) Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid- etched surface. The International journal of oral & maxillofacial implants 18: 641-651. Beer, A., Gahleitner, A. & Holm, A. (2003) Correlation of insertion torques with bone mineral density from dental quantitative ct in the mandible. Clinical oral implants research 14: 616-620. Berzins, A., Shah, B., Weinans, H. & Sumner, D. R. (1997) Nondestructive measurements of implant-bone interface shear modulus and effects of implant geometry in pull-out tests. Journal of biomedical materials research 34: 337-340. Bränemark, P., Hansson, B., Adell, R., Breine, U., Lindstrom, J., Hallen, O. & Ohman, A. (1977) Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scandinavian journal of plastic and reconstructive surgery. Supplementum 16: 1-132. Branemark, R., Ohrnell, L. O., Skalak, R., Carlsson, L. & Bränemark, P. I. (1998) Biomechanical characterization of osseointegration: An experimental in vivo investigation in the beagle dog. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 16. Brunski, J., Puleo, D. & Nanci, A. (2000) Biomaterials and biomechanics of oral and maxillofacial implants: Current status and future developments. The International journal of oral & maxillofacial implants 15: 15-46. Calandriello, R., Tomatis, M. & Rangert, B. (2003) Immediate functional loading of branemark system implants with enhanced initial stability: A prospective 1- to 2- year clinical and radiographic study. Clinical implant dentistry and related research 5: 10-20. Chang, P. C., Lang, N. P. & Giannobile, W. V. (2010) Evaluation of functional dynamics during osseointegration and regeneration associated with oral implants. Clinical oral implants research 21: 1-12. Fischer, K., Stenberg, T., Hedin, M. & Sennerby, L. (2008) Five-year results from a randomized, controlled trial on early and delayed loading of implants supporting www.intechopen.com
  • 17. Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA 127 full-arch prosthesis in the edentulous maxilla. Clinical oral implants research 19: 433- 441. Friberg, B., Sennerby, L., Meredith, N. & Lekholm, U. (1999) A comparison between cutting torque and resonance frequency measurements of maxillary implants. A 20-month clinical study. International journal of oral and maxillofacial surgery 28: 297-303. Huang, H. M., Chiu, C. L., Yeh, C. Y. & Lee, S. Y. (2003) Factors influencing the resonance frequency of dental implants. Journal of oral and maxillofacial surgery 61: 1184-1188. Huang, H. M., Chiu, C. L., Yeh, C. Y., Lin, C. T. & Lee, S. Y. (2003) Early detection of implant healing process using resonance frequency analysis. Clinical oral implants research 14: 437-443. Huwiler, M. A., Pjetursson, B. E., Bosshardt, D. D., Salvi, G. E. & Lang, N. P. (2007) Resonance frequency analysis in relation to jawbone characteristics and during early healing of implant installation. Clinical oral implants research 18: 275-280. Ito, Y., Sato, D., Ito, D., Kondo, H. & Kasugai, S. (2008) Relevance of resonance frequency analysis to evaluate dental implant stability : Simulation and histomorphometrical animal experiments. Clinical oral implants research 19: 9-14. Ivanoff, C. J., Sennerby, L. & Lekholm, U. (1997) Reintegration of mobilized titanium implants. An experimental study in rabbit tibia. International journal of oral and maxillofacial surgery 26: 310-315. Kitsugi, T., Nakamura, T., Oka, M., Yan, W. Q., Goto, T., Shibuya, T., Kokubo, T. & Miyaji, S. (1996) Bone bonding behavior of titanium and its alloys when coated with titanium oxide(tio2) and titanium silicate (ti5si3). Journal of biomedical materials research 32: 149-156. Lachmann, S., Laval, J. Y., Jager, B., Axmann, D., Gomez-Roman, G., Groten, M. & Weber, H. (2006) Resonance frequency analysis and damping capacity assessment. Part 2: Peri-implant bone loss follow-up. An in vitro study with the periotest and osstell instruments. Clin Oral Implants Res 17: 80-84. Lutolf, M. P., Weber, F. E., Schmoekel, H. G., Schense, J. C., Kohler, T., Muller, R. & Hubbell, J. A. (2003) Repair of bone defects using synthetic mimetics of collagenous extracellular matrices. Nature biotechnology 21: 513-518. Meredith, N. (1998) Assessment of implant stability as a prognostic determinant. The International journal of prosthodontics 11: 491-501. Meredith, N., Alleyne, D. & Cawley, P. (1996) Quantitative determination of the stability of the implant-tissue interface using resonance frequency analysis. Clinical oral implants research 7: 261-267. Meredith, N., Book, K., Friberg, B., Jemt, T. & Sennerby, L. (1997) Resonance frequency measurements of implant stability in vivo. A cross-sectional and longitudinal study of resonance frequency measurements on implants in the edentulous and partially dentate maxilla. Clinical oral implants research 8: 226-233. O'Sullivan, D., Sennerby, L., Jagger, D. & Meredith, N. (2004) A comparison of two methods of enhancing implant primary stability. Clinical implant dentistry and related research 6: 48-57. Oh, J.-S., Kim, S.-G., Lim, S.-C. & Ong, J. L. (2009) A comparative study of two noninvasive techniques to evaluate implant stability:Periotest and osstell mentor. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 107: 513-518. www.intechopen.com
  • 18. Implant Dentistry  A Rapidly Evolving Practice128 Park, J.C., Kim, H.D., Kim, S.M., Kim, M.J. & Lee, J.H.(2010) A comparison of implant stability quotients measured using magnetic resonance frequency analysis from two directions: a prospective clinical study during the initial healing period. Clinical oral implants research 21:591-597. Perrotti, V., Piattelli, A. & Iezzi, G. (2010) Mineralized bone-implant contact and implant stability quotient in 16 human implants retrieved after early healing periods: A histologic and histomorphometric evaluation. The International journal of oral & maxillofacial implants 25: 45-48. Rasmusson, L., Meredith, N., Kahnberg, K. E. & Sennerby, L. (1998) Stability assessments and histology of titanium implants placed simultaneously with autogenous onlay bone in the rabbit tibia. International journal of oral and maxillofacial surgery 27: 229- 235. Schulte, W. (1988) The new periotest method. Compendium (Newtown, Pa.). Supplement: S410- 415, S417. Sennerby, L. & Meredith, N. (2008) Implant stability measurements using resonance frequency analysis: Biological and biomechanical aspects and clinical implications. Periodontology 2000 47: 51-66. Sennerby, L. & Roos, J. (1998) Surgical determinants of clinical success of osseointegrated oral implants: A review of the literature. The International journal of prosthodontics 11: 408-420. Sullivan, D. Y., Sherwood, R. L., Collins, T. A. & Krogh, P. H. (1996) The reverse-torque test: A clinical report. The International journal of oral & maxillofacial implants 11: 179-185. Tozum, T. F., Bal, B. T., Turkyilmaz, I., Gulay, G. & Tulunoglu, I. (2010) Which device is more accurate to determine the stability/mobility of dental implants? A human cadaver study. Journal of oral rehabilitation 37: 217-224. Valderrama, P., Oates, T. W., Jones, A. A., Simpson, J., Schoolfield, J. D. & Cochran, D. L. (2007) Evaluation of two different resonance frequency devices to detect implant stability: A clinical trial. Journal of periodontology 78: 262-272. Veltri, M., Balleri, P. & Ferrari, M. (2007) Influence of transducer orientation on osstell stability measurements of osseointegrated implants. Clinical implant dentistry and related research 9: 60-64. Winter, W., Mohrle, S., Holst, S. & Karl, M. (2010) Parameters of implant stability measurements based on resonance frequency and damping capacity: A comparative finite element analysis. The International journal of oral & maxillofacial implants 25: 532-539. Zhou, Y., Jiang, T., Qian, M., Wang, J., Shi, B., Xia, H., Cheng, X. & Wang, Y. (2008) Roles of bone scintigraphy and resonance frequency analysis in evaluating osseointegration of endosseous implant. 29 4: 461-474. Zix, J., Hug, S., Kessler-Liechti, G. & Mericske-Stern, R. (2008) Measurement of dental implant stability by resonance frequency analysis and damping capacity asessment: Comparison of both techniques in a clinical trial. The International journal of oral & maxillofacial implants 23: 525-530. www.intechopen.com
  • 19. Implant Dentistry - A Rapidly Evolving Practice Edited by Prof. Ilser Turkyilmaz ISBN 978-953-307-658-4 Hard cover, 544 pages Publisher InTech Published online 29, August, 2011 Published in print edition August, 2011 InTech Europe University Campus STeP Ri Slavka Krautzeka 83/A 51000 Rijeka, Croatia Phone: +385 (51) 770 447 Fax: +385 (51) 686 166 www.intechopen.com InTech China Unit 405, Office Block, Hotel Equatorial Shanghai No.65, Yan An Road (West), Shanghai, 200040, China Phone: +86-21-62489820 Fax: +86-21-62489821 Implant dentistry has come a long way since Dr. Branemark introduced the osseointegration concept with endosseous implants. The use of dental implants has increased exponentially in the last three decades. As implant treatment became more predictable, the benefits of therapy became evident. The demand for dental implants has fueled a rapid expansion of the market. Presently, general dentists and a variety of specialists offer implants as a solution to partial and complete edentulism. Implant dentistry continues to evolve and expand with the development of new surgical and prosthodontic techniques. The aim of Implant Dentistry - A Rapidly Evolving Practice, is to provide a comtemporary clinic resource for dentists who want to replace missing teeth with dental implants. It is a text that relates one chapter to every other chapter and integrates common threads among science, clinical experience and future concepts. This book consists of 23 chapters divided into five sections. We believe that, Implant Dentistry: A Rapidly Evolving Practice, will be a valuable source for dental students, post-graduate residents, general dentists and specialists who want to know more about dental implants. How to reference In order to correctly reference this scholarly work, feel free to copy and paste the following: Jong-Chul Park, Jung-Woo Lee, Soung-Min Kim and Jong-Ho Lee (2011). Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA, Implant Dentistry - A Rapidly Evolving Practice, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953- 307-658-4, InTech, Available from: http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving- practice/implant-stability-measuring-devices-and-randomized-clinical-trial-for-isq-value-change-pattern-measu